How Diabetes-Technology is Changing Diabetes Treatment and the Doctor-Patient Relationship Diabetes & Technology Management Webinar 03/2020 Thomas Züger, MD UDEM, Inselspital thomas.zueger@insel.ch
Glucose Regulation in Healthy Individuals Glucose Sources endogenous exogenous «Glucose-Sensing» Blood Feedback- Glucose Glucose Loop Disposal Pancreas Insulin Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 2
Glucose Regulation in individuals with diabetes Glucose Sources endogenous exogenous «Glucose-Sensing» Blood Feedback- Glucose Glucose Loop Disposal Pancreas Insulin Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 3
https://scopeblog.stanford.edu/2014/05/08/new-research-keeps-diabetics-safer-during-sleep/ Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 4
Glucose Regulation in Individuals with Diabetes Glucose Sources endogenous exogenous «Glucose-Sensing» Algorithm Blood Feedback- controlled Glucose Glucose Loop Disposal Closed-Loop Pancreas Insulin Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 5
Closing the Loop – Artificial Pancreas Züger T et al. Ther Umsch. 2017;74(8):529-536. doi: 10.1024/0040-5930/a000953 Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 6
Low glucose suspend & smart guard Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 7
Minimed 670G – first Hybrid Closed-Loop system Algorithm Target 6.7 mM Algorithm Mealtime Insulin- Bolus by Patient Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 8
Open Source Open Source «do it yourself» • project • Realtime access to CGM- (and insulinpump-) data • Allows for intergration of different devices and algorithms to control glucose http://www.nightscout.info/ Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 9
Nightscout #OpenAPS - components Remote Monitoring Components software Current glucose (CGM) Insulin on board (IOB) Glucose change Last activity OpenAPS Last CGM-measurement Basal rate Insulin-pump Insulin stop CGM sensor/transmitter expected glucose course CHO stop -APP Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 10
#OpenAPS – data repository • 80 OpenAPS data donors, 53 years of CGM data < 3.9mmol/l; 4.3% >10 mmol/l Time in/out of range 18.2% (%, mmol/L) 3.9 – 10 mmol/l 77.5% No (Hybrid) Closed Loop 2014 – 2018 Time in range Time above Time below range (≤ 3.9 UDEM (3.9-10.0 range (>10.0 mmol/l) mmol/l) mmol/l) Type 1 DM 60.9 ±17.5 % 34.6 ± 18.6 % 4.6 ± 4.9 % Melmer & Züger et al. Diabetes Obes Metab.2019 (n=188) Züger T et al., ATTD Madrid 2020 Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 11
Technology in other areas of diabetes control 1 Glucose Sensor 5 2 Night Scout 4 3 https://apps.garmin.com/en-US/apps/2be02a1d-1d52-4db6-8bd5-6f66fe5ca992 Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 12
Sport & Diab-Tech map elevation CGM-Data Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 13
Use of Technology in Type 1 Diabetes – CH/Germany/Austria Van den Boom et al.; Diabetes Care. 2019 Nov;42(11):2050-2056. doi: 10.2337/dc19-0345 Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 14
The Tech-Paradoxon - Technology alone might not be the solution…. CGM use DM1 US-Registry 2010 - 2012 2016 - 2018 2010 - 2012 CGM use DM1 2016 - 2018 Foster NC et al., Diabetes Technol Ther. 2019 Feb;21(2):66-72. Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 15
so much data/information, so little time! YEAR 2000 YEAR 2020 16 min electronic medical record (EMR) per visit 1 2-3 min writing summary 11 min checking of blood glucose values 20 min insulin pump data + 15 min pump settings (bolus (SMBG) 2 calculator etc.) 2 30 – 40 % pat. with CGM (10 – 20 pages of CGM data) 3, 4 No continuous glucose monitoring (CGM) No wearables Integration of fitness data, meal data etc. Rare in between visits contact Mail, phone-calls, data-sharing (cloud-solutions) 1 Overhage JM et al., Ann Intern Med, 2020 2 Comellas MJ et al., Diabetes Technol Ther, 2017 3 Foster NC et al., Diabetes Technol Ther, 2019 Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 16 4 Hood KK et al., Diabetes Care, 2020
growing numbers – decreasing resources 500 Mio 420 Mio 350 Mio https://www.diabetesatlas.org/en/sections/demographic-and-geographic-outline.html Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 17
The burden of diabetes for patients with diabetes (PWD) Glucose Measurement Insulin / Drug Daily activities Visit with health & Recording Management care providers Burden of time 2005: Average 58 min a day on self-care 1 • 2018 2 : • • adult with T2DM 66 min a day • child with T1DM 78 min a day 1 Safford MM et al., American Board Fa Pract, 2005 2 Shubrook JH et al., Diabetes Spectr, 2018 Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 18
Who takes care of the diabetes management? “It is clear that diabetes remains unique among chronic conditions in the extent to which therapy is controlled by the patient and factors that shape behaviour” David G. Marrero; American Diabetes Association President Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 19
Self-adjustement of therapy between clinical visits • Survey in 47 patients with DM1 on insulin-pump (average 6 years Diabetes duration = experienced) never sometimes frequent all the time Nimiri R, Phillip M, ATTD Madrid, 2020 Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 20
Obstacles for technology utilization and self-adjustment Need to download data & contact HCP • • 50-70% of patients never download data of various devices between visits 1 • Lack of knowledge / ability / confidence Patients report low confidence and competence to • undertake retrospective review of CGM data 2 • Lack of ability to interpret data (amount of data / information overload) 3 Decision making fatigue & alarm fatigue 2 • 1 Foster NC et al., Diabetes Technol Ther, 2019 2 Lawton J et al., BMC Endcrine Disorders, 2018 3 Welsh JB et al, Diabetes Thera, 2019 Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 21
New solutions are required “digital” support in treatment optimization (for patients and health care providers) Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 22
Acceptance of automated decision support by PWD Willing to try Would you be willing to use an algorithm that adjusts your insulin pump settings 71.7% after downloading your devices at home? Would you be willing to use an algorithm that suggests insulin dosing on real- 68.1% time? Would you be willing to get text messages each time you need insulin adjustment? 50% Would you trust dosing recommendations given by automatic algorithm? 82.6% Do you think that automated algorithm for insulin dosing will release some of the 76% burden of managing diabetes? Nimri R., Carpel S, Gavan M, Phillip M, ATTD 2020, Madrid Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 23
Optimization of Diabetes-/Insulintreatment HCP Appointment, Data integration/ Telemedicine storage Local hub: (virtual patient Reporting/Transfer/ image) Display Physical security activity Diabetes data Real-time science: advice •Metabolic models glucose •Pattern recognition food •Algorithms for decision support & insulin wearables automatic control Basal insulin CHO Ratio office Reminder/info Correction factor advice Adapted from Boris Kovatchev & Bruce Bode EMR / Personalized treatment Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 24
Decision support – how it may look like for PWD The last 3 times after exercise you Ok – what do you had night-time Reduce your recommend hypoglycemia! basal insulin by 20% for 8h and eat 10g of Carbs after exercise Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 25
2020 to 2030 – the decade of the Digital Diabetes Clinic?! Consensus on Digital/Virtual diabetes clinic Madrid February 18 th 2020 – Highlights EMR Data Reminder Research Integration Transfer Messages • Digital – Virtual diabetes clinic should be developed for all patients with diabetes (PWD) • Digital clinic aim to empower PWD to self treat their diabetes Social Outcome • Data ownership should be regulated worldwide – it’s for the Decision Education Platform patients to decide whom to share it with follow-up support • Digital clinic may replace some of the F2F appointments and increase interactions between visits Visit • Easy, passive transmission of data from all different devices planning Tele- Diabetes to integrate, interpret and create a meaningful advice for both medicine (care apps HCPs and PWD priority- zation) Adapted from Phillip M, ATTD 2020, Madrid Consensus on Digital/Virtual Diabetes Clinic, ATTD Madrid 2020 Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 26
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